130 6 CHAPTER 6 2 | GOODARZI et al. 1 | INTRODUCTION Although it is appropriate for care to vary in response to local population characteristics, unwarranted variation in care has been identified as a key indicator of ineffective care and contributes to preventable morbidity and mortality.1 Variation in care is warranted if, following appraisal, evidence-based recommendations are adapted to respond to individual needs. Unwarranted variation, on the other hand, refers to large variation in care not based on population needs and/or characteristics. It is associated with inappropriate use of medical services,1–3 resulting in care that is either “too much, too soon” or “too little, too late”.4 Unwarranted variation may be caused by: (1) lack of evidence-based care; (2) differences in availability of health care resources; and/or (3) care that is provided based on providers' beliefs and interests.1–3 Studies indicate unwarranted variation in a broad range of neonatal care practices. This variation exists among practitioners, hospitals, regions, and countries,5,6 and includes substantial variation in obtaining blood cultures,7 the management of sepsis,8 and the treatment of jaundice/hyperbilirubinemia.9 In the Netherlands, considerable variation exists in rates of neonatal referral to the pediatrician among nulliparous women, ranging from 5% to 62% between hospitals10 and 37% to 60% between regions.11 Variation persists after adjustment for maternal characteristics, and maternal and neonatal outcomes have not been found to be better in regions with higher neonatal referral rates. This suggests overuse of specialist care in regions with higher neonatal referral rates.11 Reducing such unwarranted variation and ineffective care uptake requires a more comprehensive understanding of its determinants.3 Unwarranted variation is the result of complex interactions among multiple determinants.3,5,12,13 One of the determinants contributing to unwarranted variation is variation in local hospital protocols.5,12,13 Protocols are used to reduce unwarranted practice variation through standardization.13 Variation in protocols may exist between regions, between departments within the same hospital, and among practices within departments.3,5,14 The purpose of this study was to examine variation in the content of obstetric and neonatal protocols for six common indications for neonatal referral to the pediatrician: large for gestational age/macrosomia (LGA), small for gestational age/fetal growth restriction (SGA), meconium stained amniotic fluid (MSAF), vacuum extraction (VE), forceps extraction (FE), and cesarean birth (CB). We analyzed the variation in protocols between regions, between neonatal and obstetrics departments, and within neonatal and obstetrics departments. 2 | MATERIALS AND METHODS To study variation in the content of local hospital protocols for neonatal referral to the pediatrician, we conducted a nationwide cross-sectional study of all hospitals in the Netherlands with both an obstetric and a neonatal department (n = 74). 2.1 | Study sample We requested hospitals' protocols for the following six common indications for neonatal referral to the pediatrician: LGA, SGA, MSAF, VE, FE, and CB. The data were collected between September 2019 and September 2020. We contacted obstetric and neonatal departments by e-mail and asked them to send us their protocols (Supplement 1) by means of post or e-mail. The departments that did not respond received one reminder by e-mail and one reminder by telephone. The data were Correspondence Bahareh Goodarzi, Department of Midwifery Science, Vrije Universiteit Amsterdam, Amsterdam UMC, de Boelelaan 117, Amsterdam, The Netherlands. Email: Conclusions: To reduce unwarranted variation in local protocols, evidence- based, multidisciplinary guidelines should be developed in the Netherlands. Further research addressing knowledge gaps is needed to inform these guidelines. Attention should be paid to the implementation of evidence, and only where evidence is lacking or inconclusive should agreements be based on multidisciplinary consensus. Where protocols deviate from evidence-based guidelines because of specific local circumstances, clearer, more transparent justifications should be made. Uniformity in guidance will offer clear standards for care evaluation and provide opportunities to reduce inappropriate care. K E YWO R D S neonatal care, neonatel referral, pediatric consultation, protocols, variation 1523536x, 0, Downloaded from by Vrije Universiteit Amsterdam, Wiley Online Library on [14/11/2022]. See the Terms and Conditions ( on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License